Rohit Singla

Fixation of delayed union or non-union posterior cruciate ligament avulsion fractures

Purpose. To report the outcome of fixation for delayed union or non-union posterior cruciate ligament (PCL) avulsion fractures. Methods. Seven men and 4 women aged 24 to 35 (mean, 28) years underwent lag screw or suture fixation for non-union or delayed union of avulsion fracture of PCL tibial attachment after a mean delay of 8.6 (range, 4–14) months. Patient satisfaction was assessed using a visual analogue scale (VAS). Functional outcome was evaluated using the Lysholm scale. Results. The mean follow-up period was 17 (range, 8–36) months. The mean Lysholm score improved from 82 preoperatively to 92 at the final follow-up (p=0.34), the mean range of knee motion improved from 82° to 87° (p=0.008), and the mean VAS score for patient satisfaction improved from 4.3 to 7.4 (p=0.0004). All patients but one achieved bone union after a mean of 7.5 (range, 7–9) weeks. Functional outcome was excellent for 6 patients, good for 4, and fair for one. Posterior drawer test was positive (grade 1 laxity) in 3 patients whose outcome was good for 2 and fair for one. The latter had non-union after Ethibond suture repair for a communited fracture. There were no instances of wound complications or implant loosening. Conclusion. Fixation with lag screw or suture combined with bone grafting for delayed union or non-union of PCL avulsion fractures achieves acceptable functional outcome.

Arthroscopic anatomical double bundle anterior cruciate ligament reconstruction: A prospective longitudinal study

Background: Single bundle anterior cruciate ligament (ACL) reconstruction has been the current standard of treatment for ACL deficiency. However, a significant subset of patients continue to report residual symptoms of instability with a poor pivot control. Cadaveric biomechanical studies have shown double bundle (DB) ACL reconstructions to restore the knee kinematics better. This study evaluates the outcome of DB ACL reconstruction. Materials and Methods: 30 consecutive patients who underwent anatomic DB ACL reconstruction were included in this prospective longitudinal study. There were all males with a mean age of 25 ± 7.45 years. All patients were prospectively evaluated using GeNouRoB (GNRB) arthrometer, functional knee scores (International Knee Documentation Committee [IKDC] and Lysholm) and postoperative magnetic resonance imaging (MRI) for comparing the graft orientation and footprint of the reconstructed ACL with that of the normal knee. Results: The average followup was 36.2 months. At the time of final followup the mean Lysholm score was 93.13 ± 3.31. As per the objective IKDC score, 26 patients (86.6%) were in Group A while 4 patients (13.3%) were in Group B. The mean differential anterior tibial translation by GNRB, arthrometer was 1.07 ± 0.8 mm (range 0.1-2.3 mm). All cases had a negative pivot shift test. MRI scans of operated and the contralateral normal knee showed the mean sagittal ACL tibial angle coronal ACL tibial angle and tibial ACL footprint to be in accordance with the values of the contralateral, normal knee. Conclusion: The study demonstrates that DB ACL reconstruction restores the ACL anatomically in terms of size and angle of orientation. However, long term studies are needed to further substantiate its role in decreasing the incidence of early osteoarthritic changes compared to the conventional single bundle reconstructions.

Lumbar plexus injury in an anterior fracture dislocation of sacroiliac joint: a case report and review of literature

Displaced unstable pelvic fractures are commonly associated with disruption of the osteoarticular junction of the sacroiliac joint. Posterior sacroiliac dislocation are commonly reported but there are only few reports the anterior type of sacroiliac dislocation where the iliac bone fractures and displaces anterior to sacrum, often in combination with fractures of pubic rami and symphyseal injuries. We present a case of an anterior type of sacroiliac fracture dislocation which was associated with a lumbar plexus injury involving both motor and sensory components. Preoperative neurological assessment was done by MRI scan. The tented nerve roots were explored and decompressed surgically, and sacroiliac fixation was done after reduction in the fracture and joint.

Joint salvage using sandwich technique for giant cell tumors around knee.

The most common site for giant cell tumors (GCT) is knee, where the tumor characteristically extends right up to the subarticular bone plate. Extensive curettage with preservation of the joint should be done wherever possible. The alternatives for filling the void left after curettage are either bone graft or bone cement. Sandwich technique uses the advantages of both, taking care to prevent damage to articular cartilage. This study was done to evaluate the results of sandwich technique in tumors around the knee joint. It was a prospective study of 26 consecutive patients (15 females and 11 males) with Campanacci grade II and grade III GCT around the knee, which qualified the inclusion criterion and underwent knee reconstruction with sandwich technique, after extended curettage of the tumor. The mean age of the patients at the time of surgery was 32.73 ± 11.30 years (range, 18-62 years), and the mean follow-up was 3.87 ± 1.26 years (range, 6.5-2 years). At final follow-up, the functional evaluation was done using Musculoskeletal Tumor Society (MSTS) score and measuring range of motion around the knee. Three patients had recurrence of tumor; in one case, we were able to salvage the joint and repeat sandwich surgery was performed, and in the other two cases, the joint was breached; therefore, we resorted to resection arthrodesis. At final follow-up, the mean functional arc of motion around the knee and the mean MSTS score in patients without arthrodesis was 123.52 ± 10.21 degrees (range, 100-130 degrees) and 27.04/30, respectively; all patients were able to do their activities of daily living with ease. Sandwich technique is a good reconstruction procedure in GCT around knee joint with good survival rate, minimal complications, and good functional outcome.

Dorsally Comminuted Fractures of the Distal End of the Radius: Osteosynthesis with Volar Fixed Angle Locking Plates

Background. Dorsally comminuted distal radius fractures are unstable fractures and represent a treatment challenge. The objective of this study was to evaluate the functional and radiological outcome of dorsally comminuted fractures of the distal radius fixed with a volar locking plate. Patients and Methods. Thirty-three consecutive patients with dorsally comminuted fractures of the distal end of the radius were treated by open reduction and internal fixation with AO 2.4 mm (n = 19)/3.5 mm (n = 14) volar locking distal radius plate (Synthes, Switzerland, marketed by Synthes India Pvt. Ltd.). There were 7 type A3, 8 type C2, and 18 type C3 fractures. The patients were followed up at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Subjective assessment was done as per Disabilities Arm, Shoulder, and Hand (DASH) questionnaire. Functional evaluation was done by measuring grip strength and range of motion around the wrist; the radiological determinants were radial angle, radial length, volar angle, and ulnar variance. The final assessment was done as per Demerit point system of Saito. Results. There were 23 males and 10 females with an average age of 44.12 ± 18.63 years (18–61 years). Clinicoradiological consolidation of the fracture was observed in all cases at a mean of 9.6 weeks (range 7–12 weeks). The average final extension was 58.15° ± 7.83°, flexion was 54.62° ± 11.23°, supination was 84.23° ± 6.02°, and pronation was 80.92° ± 5.54°. Demerit point system of Saito yielded excellent results in 79% (n = 26), good in 18% (n = 6), and fair in 3% (n = 1) patients. Three patients had loss of reduction but none of the patients had tendon irritation or ruptures, implant failure, or nonunion at the end of an one-year followup. Conclusion. Volar locking plate fixation for dorsally comminuted distal radius fractures results in good to excellent functional outcomes despite a high incidence of loss of reduction and fracture collapse.

Early reimplantation for open total talar extrusion

Purpose. To review outcome of early reimplantation for open total talar extrusion in 7 patients. Methods. Medical records of 5 men and 2 women aged 19 to 53 years who underwent reimplantation for open total talar extrusion within 6 hours after road traffic accident (n= 6) or industrial injury (n=1) were reviewed. The talus was first irrigated with 9 to 10 litres of saline solution, followed by 10% povidone iodine. It was then reduced after thorough debridement and fixed with tension band wiring or external fixation. Ankle mobilisation exercises were started at week 6 and full weight bearing at week 14. Outcome was assessed using the American Foot And Ankle Society score. Results. After a mean follow-up of 31.9 (range, 24–46) months, the mean American Foot and Ankle Society score was 81, and the mean dorsiflexion-plantar flexion arc was 36.9° (range, 25°–45°). All patients were able to walk with a balanced, unaided gait with mild-to-moderate pain (n=3) or pain-free (n=4). No patient developed deep infection or instability. Three patients developed avascular necrosis of the talus; restriction of motion was moderate at the ankle joint and severe at the subtalar joint. None of these 3 patients opted for revision surgery, as the pain was tolerable and did not limit their daily activities, but their condition was expected to deteriorate with time. Conclusion. Early reimplantation is recommended for open total talar extrusion, as it restores (to some extent) hind foot mechanics, heel height, and bone stock for activities of daily living and future reconstructive options.

Congenital pseudoarthrosis of the clavicle with bifurcation

Congenital pseudoarthrosis of clavicle is a rare clinical entity. It usually presents as a swelling in the clavicular region at birth or soon after birth. Fitzwilliams original description of 60 subtypes of congenital pseudoarthrosis of clavicle have addressed several anatomical variants, e.g. association with cervical rib and abnormally vertical and elevated upper ribs. However, congenital pseudoarthrosis of clavicle associated with bifurcation is an atypical anatomic variant. To the best of our knowledge, this variant has never been mentioned in the literature. In the present report, we have described this subtype of symptomatic congenital pseudoarthrosis of the clavicle with bifurcation and its possible management.

Carpal bone fractures in distal radial fractures: is computed tomography expedient?

To the Editor: We read with great interest the article “Evaluation of associated carpal bone fractures in distal radial fractures” by Heo et al. We would like to congratulate the authors for this study. However, the article left a few seminal questions unaddressed that we would like to draw the authors’ attention to. The authors mentioned that out of 223 fractures of the distal end of the radius, which were subjected to computed tomography (CT) evaluation, 46 patients had an associated carpal-bone fracture. They were silent, however, about how many of these associated carpal bone fractures were picked-up on plain X-rays. A CT undoubtedly helps in diagnosing undisplaced or minimally displaced fractures; however, this cannot be the story in all cases. Indeed, plain radiographs can definitely aid in diagnosing the obvious, if not all of these fractures. Type C2 and C3 are a result of high-energy trauma, and 40 out of the 46 cases of the carpal bone fractures were identified in these fracture subtypes. If we go by the current study, the incidence of carpal bone fractures is 28.36% in these two types as against 4.87% in all other types combined together. High-energy trauma has been found to be associated with a higher risk for associated carpal bone injuries. Thus, it would not be wise to perform screening CT scans for all fracture types. It is an expensive investigation that subjects a patient to substantive amounts of radiation exposure. Moreover, in a recent study by Jorgsholm et al., it was identified that even a CT scan is not always 100% sensitive in diagnosing carpal bone fractures and some of these fractures are liable to be missed on a CT as well. It is important to decide a treatment protocol, rather than subjecting all patients with distal radius fractures to CT examination. Patients with Type C2 and C3 types should be looked with a high degree of suspicion and as approximately one-third of them have been found to be associated carpal bone fractures, mobilization can be delayed as it does not lead to unsatisfactory outcome. Moreover, there is a high incidence of associated soft tissue injury in these patients perpetuated by high energy trauma. Delayed mobilization will also aid in healing of these injuries.

Retrograde Intramedullary Nailing for Distal Femur Fractures with Osteoporosis: An Appraisal: To the Editor

To the Editor: We read with great interest the manuscript by Kim et al. entitled “Retrograde Intramedullary Nailing for Distal Femur Fracture with Osteoporosis” in the current issue of your journal. We must congratulate the authors for this study. However, we would like to elaborate on few points and would like to draw attention of authors and readers to the following: 1. Filling void in comminuted fractures by bone cement inadvertently exposes the fracture site. Fig. 1 shows the distal femur exposed from its lateral to medial aspect. Thus, the concept of biological fixation is defeated. Submuscular bridge plating in such a scenario, allows for closed reduction of the diaphyseal/metaphyseal component of the fracture. One needs to take care of the length, alignment and rotation, and no anatomical reduction per se is required. With minimally invasive percutaneous plate osteosynthesis (MIPPO), favorable biological fixation for distal femoral fractures can be achieved, fracture haematoma is preserved and bone grafting is not required even in the case of metaphyseal communition. The authors should mention this drawback of cement augmentation and advantages of MIPPO in this subset of patients. 2. The authors did not mention the length of the nail they chose. A long retrograde nail is crucial for the stability of such fractures. In osteoporotic patients, the medullary canal tends to become very wide in the metaphyseal region which can be a risk factor for secondary displacement in varus or valgus depending on the nature of the fracture. Longer nails that achieve support in the isthmus region of the femur or incorporation of Poller screws that are close to the nail solves this problem. Longer nails provide improved initial fracture stability when compared with short retrograde nails for supracondylar femur fractures due to a more stable mechanical interaction between the femoral diaphysis and the nail. This also needs to be addressed. 3. The authors also did not mention weather they used one or two proximal locking screws, though the images (Figs. 1 and 2) show two proximal locks. A second proximal locking screw is not known to provide any additional stability; rather the presence of proximal lock below the lesser trochanter is known to lead to a stress riser. A single lock in a long nail saves surgical time and averts a stress riser and a fracture in the already osteoporotic bone. 4. The post operative treatment protocol is not clear. The authors used the statement “Weight bearing was allowed at 6th postoperative week.” Postoperative rehabilitation depends upon the stability of fixation and fracture pattern and has to be individualized for each patient. Due to expanding trumpet shape of distal femur , in case of unstable fixation, when the fracture site is subjected to stress the nail may move within the bone; therefore it is necessary to provide splint age in such situation. If the authors initiated continuous passive motion from day 1, meaning that they probably were able to attain stable fixation in all cases. If such is the case, partial weight bearing can be started immediately after surgery with ambulatory aids, though full weight bearing walking can be delayed until evidence of callus formation. The whole purpose of stable fixation is defeated if walking is delayed. The authors should explain their postoperative rehabilitation protocol more clearly. 5. Many studies have highlighted the need for dynamization after retrograde nailing. The need for dynamization of the implant to achieve fracture union has been reported to be as high as 19%. The authors remained quiet about this procedure. 6. Knee pain, though mild, is common after retrograde nailing with the incidence ranging from 13% to 60%. The authors did not make any comment about this in their series.

Longitudinal Bracketed Epiphysis of Proximal Phalanx of the Great Toe With Congenital Hallux Varus Managed Simultaneously With Monorail External Fixator A Case Report

Longitudinal bracketed epiphysis (delta phalanx) is a rare congenital anomaly that affects phalanges in the hand more commonly than toes. We present a rare case of congenital hallux varus with longitudinal bracketed epiphysis of proximal phalanx with bifid distal phalanx of the great toe, which was managed with monorail type of external fixator. To the best of our knowledge, this is the first report of its successful implementation in simultaneous treatment of longitudinal bracketed epiphysis of the proximal phalanx of the great toe and hallux varus. Apart from adding to the literature a case of rare subtype of delta phalanx with hallux varus, the present study highlights the role of a reliable alternative in its management. Levels of Evidence: Therapeutic, Level IV, Case study